Thursday, February 9, 2006
BMJ e-published this article on a meta-analysis of factors influencing location of death. (pdf here) This article made me think of two families I recently consulted on and how they came to their decisions regarding taking the patient home to die or staying in the hospital. There were many similarities to between the patients and families, same disease, same disease course, similar family structures with lots of support, same race and socioeconomic status, etc.
But the main difference between the two was their style of coping. One family was full of 'adapters' and 'do-ers' the other family was much more passive and hesitant to commit to anything. Obviously these factors would be very difficult to study, but since Kansas City Hospice (my organization) will be opening an inpatient hospice home in the next few months, it makes me wonder how the first inpatient facility in the Kansas City area will impact discharges from hospitals for patients with a prognosis of days. In my fellowship we had an inpatient facility called Kate B. Reynolds (after a heir of the RJ Reynolds company...hey it was Winston-Salem, NC after all), and I could not imagine what it must have been like without an inpatient facility as a discharge option, but since I have moved to KC it is pretty obvious. Many families, except the 'adapters' stay in the hospital with the patients until the patients die. All of this wandering commentary brings me to the important point of the article in the discussion section...
Actions to enable people to die at home should prioritise ways of empowering families and public education, balanced with a continuing effort to improve home based models of care (assuring intensive, sustained, and coordinated home care), early and continuous risk assessment, and training on palliative care not just for specialists but also for primary care professionals.
So with that in mind make sure to read my earlier post about contacting your legislator about Medicare Hospice cuts. Can't avoid deaths and crisis stays in the hospital if hospice agencies cannot supply the staff to assist families!
I have to comment that I really enjoy BMJ's format. A couple of key things stand out that I wish other major journals would adopt. One is the Summary box on 'What is already known on this topic' and 'What this study adds'. The other part is the very end after the acknowledgments where every article cites 1) funding; 2) competing interests; and 3) ethical approval. I always find that interesting reading.